125 WASHINGTON ST -PERMIT APP 4-236 ROOF S�
"PLIkm M111 T-BE f*L f/D:APPROVED 13Y T44E
=PEXTDA ,PWR TO A_PERMIT BEwG GRANTED
CITY OF SALEM
No. '��-2�so Date
h
2 �.. .
,_2a� 4s'i
NE
Is Property Located in Location of (��
the Historic District? Yes_No_ Building IM N
Is Property Located in
the Conservation Area? Yes_No _
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
e air/Replace, Other:
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The.undersigned hereby applies for a permit to build according to the following
specifications t (GA �"
Owner's Name X-
Address & Phone 3D t w.e 9 w
Architect's Name
Address & Phone ( 1
'\J Mechanics Name
x Address & Phone
What is the purpose of building? rDNb US
Material of building? If a dwelling, for how many families? 4fnN D DS
Will building conform to taw? Asbestos?
U
Estimated cost �,rn 52
isi City License# N A State License #
Home Improvem t
Lic. rl l332Ir
— 4 Signature of Applicant
C-( L� SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION .OF WORK TO BE DONE
MAIL PERMIT TO: X J2 L�UINg jYVN tJYly� lco{� G�v��s�
s
4
4)D P4FL '"oo s -r �5 prp r-�-
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No.
APPLICATION FOR
PERMIT TO
LOCATION.
PERMIT GRANTED t t
APPR FID
X
INSPECTOR O UILDINGS '
f
V
{ . OF .5ALEM. tYrc.:DZ/-k4mw .-
PUBLIC PROPERTY DEPARTMENT ��
e3° ' 120 WASHINGTON STREET, 3RD FLOOR CLI �N
SALEM,MA0197O p OPD <gQ(�K)
TEL. (978)745-9595 EXT.380 ��' 2�Qj—
�� FAX (978) 740-9846
rLEY J. USOVICZ, JR.
MAYOR
r ( 23 � " " (
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40,S34,I acknowledge that as a condition
of Building Permit# 133 all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL eIH,S150A.
The debris will be disposed of at 'a� v>1
Location of Facility
gnature of Permit Applicant Date
FULLY complete the following information.
(PLEASE PRINT CLEARLY) \
SC.OT � S � Cc�c7L�� l
Name of Permit Applicant
6 Firm Name,if any
>P x oo�ti
Address, City & State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIII,S 150A, and the building permits or licenses are to
indicate the location of the facility.
—� Cornmonwrahk of 11(a6eac`lusgffd
Fa =
—:Jtpar�mcnf o/..7�ial �cciat�
BarnesJ.ea,n tel Uoa(oM ,,,ac/t,u.itf OZf /1
Coramrssa w
Workers' Compensation'lasuranee Affidavit
11 _� r n"t� -z) C ,CC) O llf�ex (ay..vr.r.pat)
with.a principal place of business at:
3� L '�.I ncls in 4J� `Pecn�OCIL, 019 0
do hereby certify under she pains and penalties of perjury, that:
() 1 am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
I am a sole proprietor and have no one working for me in any capacity.
O I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
I unoerwna mat a coon of"Rater ent W,1 be iorraroed to cht Orrice 7 Imrtsdtaoons of the DIA for co.eratt•eti&adon ano that laiurt to uwrt
coreratr as reeurto unatr Section ISA of MGt I S 2 can Itad to the inn dcfl of crkninal cen njies cor_wtint of s fine of vo tot 1.500CD and/.ON
ytan•imaruonn+mt v.,ra as cirii "wities in the form of a STOP WORK ORDER ano a rinse of S 100.00 a am ata+nt me.
Z fs e Zo 3
Signed this day of
�i • ee/Fcrmittee building Departrtient
Licensing board
Seleamens Office
Health Department
v \ E;Jr COVE;.f-.GE
_ iON CALL: i7.7'-7-4900 X40= , 40'q c0c 409, 375
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HOMEIMPROVEMENTCONTRACTOft $�
!, �Registra`tron 133248
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'A NORTHERN ROOFING 8`CONSTRIICTION CORP. to
L SCOTf CROOKER aj
32 LIVINGSTON 6R
PEABODY,MA.01460 . Administrator - ;i